Community outreach and technology have proven to be invaluable in maternal and neonatal health programmes in three states
Ash can be a killer, especially for newborns. At 1.97 kg, Sumati* was born underweight and in danger when a visit by the local Asha (accredited social health activist) to the day-old baby’s village, Kanudih in Uttar Pradesh’s Varanasi district, revealed a malady common in these parts — an infected umbilical cord.
Sumati was found to be too weak to breastfeed and running a fever, but the real villain of the piece was the ash applied to the child’s umbilical cord, supposedly to quicken the healing process. As it did for Sumati, this local practice often causes sepsis, which is one of the reasons rural Varanasi has an infant mortality rate of 55 babies per thousand, close to double the national average of nearly 31.
Infections of the kind are not the only peril for mothers and infants in Varanasi, where four out of five high-risk babies — those born premature, with low birthweight or unable to be breastfeed — die due to lack of proper medical care. The picture is just as dismal in many other regions of India.
The maternal mortality rate (women dying during childbirth) in the country stands at 122 per 100,000 births. The Indian government’s goal is to bring the figure down to 70 by 2030 and the infant mortality rate to 25 per 1,000 births over the same period (both in line with the United Nations’ Sustainable Development Goals). And it needs help to achieve this linked double target.
The Tata Trusts’ maternal and neonatal healthcare programme is aimed at providing just that sort of help. One of the big interventions here is the Mission Asha project in Varanasi and another is ASMAN (Alliance for Saving Mothers and Newborns), running in Rajasthan and Madhya Pradesh. The broad goals of the two initiatives are the same: strengthening the capabilities of state healthcare systems. But they are quite different in their details.
Mission Asha has taken the community outreach approach to improve home-based care for high-risk infants like Sumati. Started in October 2019, it will eventually cover nearly 2 million people in 1,295 villages and directly benefit some 56,000 babies every year. At the heart of the endeavour is the training of some 2,000 government-appointed community health workers — the Ashas — to reach out to new mothers.
Involving about 20 team members, the programme has trained 900-plus Ashas in home-based care. Most of the training happens in the field, with the Ashas learning to weigh babies, take temperatures, clean the umbilical cord, keep records, etc. The most important facet here is identifying and providing care to high-risk births as quickly as possible.
“The first 48 hours are critical,” says programme officer Charu Johri. “If we fail to check the baby within that time, the risk of death is very high.” To ensure adherence to the 48-hour deadline, each team member visits 15-16 babies every day along with designated Asha workers.
The team gets information on births from the district health system and nurses and midwives at health centres use Whatsapp messages to report infants at risk.
With every birth reported, the project team calls the local Asha to visit the child’s home as soon as possible. The baby is weighed, the temperature is taken and the mother is shown how to keep the baby warm and breastfed. Educating families to desist from using ash and feeding anything but mother’s milk is part of the agenda. As with Sumati, the team provides medicines where necessary.
These simple home procedures have been a boon for mothers and their infants in Varanasi. The Ashas, who typically have to deal with breastfeeding issues, cord infections, hypothermia, pneumonia and sepsis, have made a difference where it matters. “Our project processes for reporting cases, managing equipment and supplies, and offering incentives to Ashas have helped,” says Ms Johri.
With ASMAN, the other significant project under the Trusts’ maternal and neonatal healthcare umbrella, technology is the star element. A collaboration involving the Trusts, the Bill & Melinda Gates Foundation, MSD for Mothers, Reliance Foundation and the United States Agency for International Development, ASMAN was launched in 2017 in four districts each of Rajasthan and Madhya Pradesh.
The initiative is geared to improve the quality of care for pregnant women at government facilities, especially during the critical labour and immediate post-delivery periods. Technology, in the form of a tablet-based protocol, is used at the patient’s bedside with a simplified checklist tool that guides nurses through safe deliveries. The tablet monitors patients and fetal heartbeats, sends out alerts to doctors in emergencies, and uploads data onto a government dashboard.
Nurses are the most important personnel in the process. Says Pratibha Nagtilak, the Tata Trusts lead on the project: “Typically, it is the nurse who is present through the delivery. She needs to be properly trained to handle complicated cases. The tablet has a decision-support tool that guides her through the protocols for difficult cases.” Close to 950 nurses have been trained to use the technology.
The tech aid gives the nurses confidence to handle complicated cases, boosts their knowledge and minimises the drudgery of paperwork. It also speeds up patient referrals from one centre to another, besides enabling health workers and officers to monitor and manage high-risk cases in real time.
Getting all stakeholders on board has not been easy. The project team often has to handhold staff nurses to ensure that data is accurately seeded and doctors have to be prodded to check up on high-risk cases. But the effort is paying off in terms of numbers and patient experience at the 81 facilities in the initiative. That explains why the Rajasthan and Madhya Pradesh governments are now rolling it out across all districts of the two states.
Playing this game can save lives. The ASMAN programme uses a game-based method, developed by Bodhi Health Solutions, to train nurses, with 29 game scenarios that simulate real-life cases such as maternal sepsis and pre-eclampsia.
Nurses play the game on their mobiles and go through five levels of increasing difficulty. Loaded with images, patient history, obstetric history, vital parameters, etc, the training thus imparted helps nurses identify high-risk cases and decide quickly on proper treatment.
Counselling nurses to play the game regularly is one of the tasks under ASMAN. Nearly 550 nurses are on this playlist and nearly 200 have finished all the levels. The project has built in an element of competition: nurses can see other participants’ scores and this spurs them to keep playing to do better. The winners in this game are the mothers and babies.